Basic Info
Name
*
First Name
Last Name
Phone Number
*
Alternative Phone Number
*
Email (if you check regularly)
example@example.com
How many adults in your household?
*
How many children in your household?
*
Back
Next
Housing Status
Where did you sleep last night?
*
In a home I own
Temporarily living with Friends or Family or "Doubled-up"
In my own rental
Shelter
Streets/Car or other place not meant to be a sleeping space
Hospital or Treatment facility
Jail/Prison
Hotel/Motel
Foster Care/Group Home
Back
Next
What brought on your housing crisis?
*
I have an eviction noticebecause of unpaid rent or utilities in the amount of...
I have an eviction notice for non-financial reasons. List Reasons...
I don't have an eviction notice, but I am struggling to pay my rent.
My home is going through foreclosure
I'm not in foreclosure, but I am struggling to pay my mortgage.
I'm being asked to leave my doubled-up situation by friends or family.
My house or apartment has been condemned or is unlivable.
I am unsafe in my current housing.
My current housing situation is over-crowded.
Provide amount
List reasons
Back
Next
Are you safe in your current living situation?
*
Yes
No
Back
Next
Is there any possibility of you staying in your current housing situation for the next 3 to 7 days?
*
Yes
No
Back
Next
Is there any other housing options you could access for a t least the next 3 to 7 days?
*
Yes
No
Back
Next
What support would you need to make this happen? For example no assistance needed, mediation, financial assistance, case manager assistance, legal aid or fair housing referral. List needed supports here...
*
Back
Next
Are there other resources or services that you need to access? Check all that apply.
*
Food Assistance
Survival Supplies (warm clothes, sleeping bag...)
Energy Assistance
Transportation
Immediate Shelter
Other
Submit
Should be Empty: